Drug use during pregnancy is associated with adverse prenatal and post-natal consequences. Despite these complications, an alarming number of women are unable to cease drug use once they become pregnant. This population has a number of medical, obstetrical, psychosocial and psychological needs that challenge the skill of providers and the resources available to the treatment community. Novel approaches are needed to effectively treat drug abuse during pregnancy and to prevent postpartum relapse. This article reviews the prevalence of substance use during pregnancy; presents barriers that impede treatment access and retention for pregnant women; and presents a novel behavioral intervention, Reinforcement-Based Treatment (RBT), for initiating abstinence and preventing relapse in this vulnerable population.

The adverse consequences of drug use during pregnancy are well known. Systematic methods for assessing and quantifying drug use during pregnancy do not exist; therefore, the rate of infant drug exposure is unknown. In a survey of pregnant women aged 15 to 44, 18 percent reported smoking cigarettes; 9.8 percent reported drinking alcohol in the past month; and 4 percent reported using one or more illicit drugs in the past month (SAMHSA, 2005). Since many estimates are based exclusively on self-report, these numbers are likely underestimates of the true prevalence of licit and illicit substance use during pregnancy. Prevalence estimates of illicit drug use in cities with large teaching hospitals are much higher, ranging from 11 percent to 40 percent of pregnant patients receiving care at these facilities (Jansson & Velez, 1999). Chasnoff and colleagues (1990) found that 15 percent of women tested for drug use at first prenatal care visit were positive for one of more substance.

Pregnant, drug-dependent women often enter treatment with a complex picture of medical, psychological, and psychosocial needs. They frequently have medical conditions related to drug use or a drug-using lifestyle, including: infectious diseases such as hepatitis B and C and HIV; sexually transmitted diseases; cellulitis; abscesses; and endocarditis (Jansson, et al, 1999). Pregnancy-specific complications of drug use include miscarriage, premature labor, preeclampsia, and infant outcomes such as intrauterine growth retardation, low birth weight, and neonatal abstinence syndrome (Svikis and Higgins, 1996; Finnegan, 1991).
It remains unclear whether adverse maternal and infant outcomes are the result of substance use, the interaction among multiple substances (including nicotine), and whether these interactions are further complicated by other factors, including poor maternal nutrition. The status of these pregnancies is often further compromised by sporadic, late or no prenatal care (Wheeler, 1993).

Treatment barriers
Unfortunately, pregnant women who need substance abuse treatment face many barriers to receiving adequate care. These barriers are both systemic (existing within the treatment system), and psychosocial (within the individual’s environment). Systemic barriers include: a poorly integrated treatment setting (services at different locations, by different providers); lack of female-oriented programs; limited program resources (i.e., transportation, outreach, and on-site childcare); and confrontational or punitive treatment providers.

There are many psychosocial impediments to accessing treatment for women including: the stigma associated with female substance use (particularly during pregnancy); fear of reprisal from child protective services or the legal system; psychiatric disorders; a history of trauma that interferes with treatment engagement (including physical, sexual and/or emotional abuse); domestic violence (i.e., partner may become abusive if she enters treatment); drug use by current partner (i.e., the woman wants to be abstinent but has difficulty because her partner is still using); and a general lack of social and familial support to encourage treatment access and success.

In addition, impoverishment rates among substance abusers serves as a barrier to treatment access and retention. Limited financial resources (for example, to pay for transportation), no access to a phone, inadequate childcare, and lack of health insurance are a few of the many impediments to treatment engagement. Homelessness is prevalent among treatment seeking pregnant women, and research has shown that homeless women are more likely to drop out of treatment and relapse compared to domiciled women (Tuten and Jones, 2003). The basic needs of this population must be considered when devising ways of improving their access to substance abuse treatment services.

Need for comprehensive care
Given the recidivism rates among substance abusers, comprehensive, multidisciplinary treatment offers the best chance for success. In a population of pregnant women where the needs are even more severe and complex, comprehensive and well-coordinated treatment is paramount. Ideally, treatment should be provided in a setting where multiple services are provided at one location, including: prenatal care, substance abuse counseling, mental health treatment, parenting/family skill building, transportation assistance, childcare services, and methadone treatment, if appropriate (Jones, et al 2006).

Intensive drug interventions are needed to treat the unique and complex needs of pregnant women. Sound interventions should strive to eliminate the many barriers that impede treatment access and retention. Effective interventions also must be firmly grounded in both theory and empirical evidence. Additionally, treatment should focus on the individual circumstances that maintain drug use, and reinforce alternative behaviors. The following describes a behavioral treatment that is being evaluated in pregnant drug-dependent women who are not receiving medication treatment.

Reinforcement-Based Treatment
RBT is an incentive-based drug free treatment program modeled after the Community Reinforcement Approach (CRA) (Budney and Higgins, 1998; Meyers and Smith, 1995; Roozen, et al 2004). This treatment model combines both individual and group activities, provides the women with specific feedback regarding their histories of drug use, and strives to highlight the treatment atmosphere as a tool for reinforcing attendance and exposure to treatment incentives.

In the context of a day treatment program, individual counseling is supplemented by abstinent-contingent support for housing (rent payments); skill building groups (i.e., drug refusal skills, HIV education); food and recreational activities; and vocational assistance. Many of the program benefits are offered only while drug free urine and breath samples are being submitted in a contingent abstinence model designed to motivate and maintain abstinence. More intensive treatment is provided early in the intervention, when the risk for relapse is greatest (i.e., attendance seven days per week), and titrated down gradually over a six-month course of treatment.

Conceptual foundation
The RBT model is based on the behavioral principle of operant conditioning. Operant conditioning proposes that behavior is strengthened or reinforced, based upon the consequences resulting from that behavior. Another important behavioral consideration is the stimuli (events or cues) in the environment that influence behavior.

According to the RBT model, the best way to reduce and eliminate drug use is to adequately compete with it. In simplistic terms this would mean that the behavioral therapist would focus on two main goals of treatment: developing alternative reinforcers for drug use; and removing the individual from environmental stimuli that “trigger” drug use.

The following are some of the key components of RBT treatment.

Functional Behavioral Assessment
Functional Behavioral Assessment (FBA) includes a variety of procedures for examining the antecedents and consequences of a behavior so that the function, or purpose, for that behavior can be identified (Gresham, Watson, & Skinner, 2001). According to the theory of operant conditioning, the two broad main functions of behavior are positive reinforcement and negative reinforcement. In determining the function of a particular behavior, the therapist can develop interventions that will serve a similar function to the target behavior that needs to be reduced or eliminated. For a substance abusing population, drug use is the target behavior (often multiple drugs), and the goal is abstinence (elimination of drug use behavior).

The functional assessment provides a systematic and thorough evaluation of the conditions under which drug use occurs. A thorough FBA will include self-reported information gathered from the client, as well as data from standardized assessments (i.e, the Addiction Severity Index [ASI]), and ideally should also include observations from significant others. The program utilizes a functional assessment form to gather the following information: which drugs are being used (including the specific order (if multiple drugs are used), as well as the quantity of the drug(s) used); when drugs are being used (how many times a day, at what times); where substance use occurs (i.e., on the street, in a crack house, at home); and what precedes (antecedents) and follows (consequences) drug use. The antecedents and consequences of behavior provide the therapist with information on what is eliciting and maintaining drug use. (See Figure 1 for a flow sheet of the FBA process.)

In addition to the conditions for drug use, an individual’s longest period of abstinence also should be assessed. Past behavior is the best predictor of future behavior; therefore, therapists should attempt to mimic the conditions of success as closely as possible. For example, if an individual reported that she remained abstinent for six months when she was going to church, attending Narcotics Anonymous (NA), and working, then these activities should be considered for inclusion in the client’s current treatment plan. More on setting and reviewing treatment goals is discussed in the behavior monitoring section.

Treatment planning
The primary objective of RBT is client abstinence. Therefore all treatment goals should directly support this primary objective. Once an initial functional assessment has been completed, the therapist and client choose treatment goals that most approximate the function that drug use serves for the individual.

Atmosphere of reinforcement
The most basic and perhaps most overlooked resource of any agency is a reinforcing atmosphere of care. Treatment should be somewhere clients feel comfortable, and every effort should be made to ensure that the treatment setting is one that clients will want to revisit for ongoing treatment, and in the event of a relapse. From the initial contact with clients, the RBT therapist expresses confidence regarding the client’s decision to come to treatment, and assures the client that it offers her a good chance of remaining abstinent for the long-term.
All agency staff should contribute to a welcoming atmosphere for the client by taking steps, such as making sure that all clients are greeted warmly when they first walk through the door; offering refreshment, such as coffee and water; providing a clean and inviting physical atmosphere; and ensuring that adequate time is set aside for each client.

Tangible reinforcers are of little or no cost, but may also serve to create a positive treatment atmosphere. Some tangible resources may include congratulations slips for negative urine samples, and congratulations cards to highlight a particularly successful endeavor (i.e., gaining employment). Every interaction should be viewed as an opportunity to engage clients in treatment and to create a relaxed and nonjudgmental setting.

Behavior monitoring
Clients tend to think of their drug use as a chaotic occurrence that “just happens.” This chaos needs to be minimized by identifying the antecedents and consequences of drug use, and making the connection between these conditions and the client’s drug use. Graphs are one behavior monitoring method that offer clients a visual depiction of their treatment activities. All abstinence-supporting goals are recorded on a graph and reviewed with the client on a regular basis. The client interprets her new interests (NA attendance, work, recreational activities) as activities that are supporting her abstinence. Conversely, clients also are informed that changes to the treatment goals or level of activity create the conditions in which a relapse is likely to occur (i.e., not attending NA, quitting a job, etc.).

By monitoring behavior graphically, clients actually see what they are doing right, and the therapist can reinforce each small step toward goal achievement. Treatment goals should be translated into small, manageable concrete steps so that clients experience success. For example, an appropriate treatment goal for a client with a very poor work history would be to have her submit 10 job applications per week. This goal is ambitious, in keeping with the intensity of RBT treatment, and is also specific and measurable, allowing for proper monitoring. The job seeking behavior is reinforced even though the longer-term goal of acquiring employment has not yet been accomplished.

Through the identification of goals that effectively compete with the individual’s drug use, the therapist creates opportunities to reinforce client efforts. Conversely, when goals that were previously met are no longer being met, graphs will indicate an impending relapse. For example, if a client had 60 days abstinence while going to NA, working, and spending time with her daughter, but has recently begun missing work and not attending NA, the therapist would address concerns of a possible relapse with that client.

Client feedback
Personalized client feedback is another method for connecting behaviors to drug use. Individualized feedback has been used with a wide range of populations, and has shown effectiveness in reducing problem behaviors, including substance use (e.g., Bien, Miller, & Tonigan, 1993b). Feedback is personalized, and objective information is provided to the client regarding her healthy behaviors (i.e., entering treatment, taking prenatal vitamins); unique history of drug use (i.e., including quantity and frequency); risk factors (i.e., HIV risk); the costs and benefits of drug use; and her motivation to remain abstinent. Feedback should be provided to each client within the first two weeks of treatment, as it provides valuable information about both the positive and negative consequences of drug use. One of the most influential aspects of feedback is recording the amount spent on drugs (lifetime). It is not unusual for clients to have spent $300,000 or more on drugs (lifetime), and this allows them to consider what they could have purchased instead of drugs (i.e., a house).

The goal of feedback is to shift the client’s perception that substance use is random or outside of her control, to a perception that there are reasons and predictable patterns of drug use that can be anticipated and changed. Feedback also helps clients who are ambivalent about their drug use to weigh the pros and cons of drug use and to explore these in comparison to their goals for themselves and their children.

Outreach
Of key importance to this program is conducting outreach for clients who have missed clinic appointments or who have relapsed. Clients in drug treatment may avoid treatment when they have relapsed, often feeling that they have failed. Previous experience with providers who have berated them for relapses may also impact this reluctance to return to treatment. Outreach efforts are made as soon as possible after a client loses contact with the therapist. The sooner the outreach is made, the more likely the client will get back into treatment. Getting the client to return to treatment will minimize the effects that a relapse has on the gains made to date. For opiate dependent clients it may also avoid another detoxification.
If the client is simply non-compliant with treatment, outreach may provide a buffer against relapse by returning the client to the treatment environment before drug use can occur. Or, if the drug use episode can be minimized to a one-time use, then detoxification will not be necessary, and the client will be able to resume treatment without much disruption. Therapists should try several methods to re-engage clients including telephone calls, letters, visits to the home, and contact with family members. As with all of the elements of RBT, therapists are supportive, understanding, and accepting of clients upon their return to treatment. Clients are encouraged to “get back on track” with their recovery work, rather than being told they have negated all gains previously made in treatment. Clients frequently report that the efforts made by staff, and the feeling they are cared for and welcomed back in treatment are the reason they decide to return to treatment.

Abstinent-contingent housing
Abstinent-contingent housing is paid for, provided the individual is drug free. Where a person is living (including on the street) can serve as a strong cue for drug use. Providing women with safe housing allows for a “time out” from drug use and associated stimuli. In the RBT model, women are provided recovery housing for six months, contingent on the provision of drug free urine samples. Recovery housing consists of living quarters for people who are recovering from addiction. Typically, these are apartments that are owned and/or managed by other individuals in recovery, with structured activities (i.e., NA attendance) and resident rules (i.e., curfews).

Our experience has been that women who remain in recovery housing have much higher success rates than women who return to housing where they have previously used drugs. If a woman refuses to enter recovery housing, or is forced to leave due to repeat relapses, all efforts are made to identify safe housing alternatives in the community, either with family members, or as a last resort, in temporary shelters. When the client refuses or cannot move into recovery housing, alternative housing (the next safest place) should be arranged. When the client refuses to move from an area or house where he/she has used drugs, plans should be made to ensure that no drug paraphernalia remain in the house, and that the client avoids all streets where she bought drugs, as well as all people with whom she has used drugs.
While recovery houses are ideal settings for women in early recovery, therapists must be willing to find alternatives to ensure that women have adequate housing at treatment discharge. Finding appropriate housing for pregnant women is not an easy task, and as such, therapists must work diligently to develop relationships with community providers to ensure that all available resources are identified.

Research support
In a randomized trial with cocaine and heroin addicted men and women (Gruber, Chutuape, & Stitzer, 2000) receiving brief (one month) treatment, RBT was superior to standard community treatment in retaining clients in treatment and maintaining their abstinence. The RBT participants also showed less evidence of depression and higher rates of employment than did their counterparts in the standard treatment condition. In a second study (Jones, Wong, Tuten & Stitzer, 2005), RBT produced significantly higher self-report and urinalysis-confirmed rates of abstinence from opioids and cocaine relative to usual care at one and three months during treatment.

Also noteworthy is that participants in the RBT condition showed significant increases in number of days worked and amount of legal income earned at three, six, and 12 months. A large-scale clinical trial is being conducted with drug dependent pregnant women receiving RBT and comprehensive care versus women receiving comprehensive care alone. Preliminary results show that the RBT group remains in treatment for significantly longer and is far more likely to remain abstinent compared to the standard care group.

Discussion
Drug use among pregnant women is best addressed in a setting that provides comprehensive services to address the many needs of these high-risk pregnancies. Great strides have been made in substance abuse treatment for pregnant women, with services becoming more integrated and specialized. Yet, much work remains to be done to improve abstinence rates and maternal and infant outcomes. Empirically supported treatment interventions hold the most promise for preventing relapse and maintaining abstinence for the longer term.

The RBT model provides services that are behaviorally sound and intensive enough to compete with the retractable and difficult problem of substance use. RBT is designed to teach women new skills, and to provide them positive experiences with non-drug using behaviors. One frequently overlooked element of treatment, that is of no cost to providers, is providing an atmosphere that routinely reinforces women for being present in treatment and for the difficult and hard work of recovery. Because women learn new skills (i.e., exposure and practice at performing non-drug using recreational and social activities), this approach holds promise for generalizing treatment gains to the “real world” environment in which these individuals live. The hope for this model is that women will replace their drug using routines with healthier and more reinforcing lifestyles, and that their children will develop in a healthier environment.

Further research is needed to determine the full effectiveness of this treatment model, as well as discerning which of the model’s components (i.e., housing, recreation, individual therapy) are most associated with abstinence. Knowledgeable and dedicated providers have an opportunity to further improve drug treatment for pregnant women by utilizing behavioral interventions to reinforce healthier lifestyles.

Michelle Tuten, MSW, LCSW-C, Instructor Johns Hopkins University School of Medicine, oversees the clinical integrity of research interventions using RBT, motivational interviewing and voucher incentives.

Hendree Jones, PhD, Associate Professor Johns Hopkins University School of Medicine, is the principal investigator for four federally funded grants examining behavioral and pharmacological treatments for pregnant drug-dependent women.

Jennifer Ertel, MS, is a lead substance abuse therapist at Johns Hopkins University, and is currently pursuing state licensure as a professional counselor.

Judith L. Jakubowski, MA, is a substance abuse therapist at Johns Hopkins University, providing behavioral treatment to men and women living with addiction, and specializing in treatment for pregnant drug-dependent women not on methadone maintenance.

Joan C. Sperlein, BS, is a substance abuse therapist at Johns Hopkins University, providing behavioral treatment for drug free and methadone maintained men and women.

References
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Finnegan, L. P. (1991). Perinatal substance abuse: Comments and perspectives. Semin. Perinatal., 15, 331-339.
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This article is published in Counselor,The Magazine for Addiction Professionals, June 2006, v.7, n.3, pp.22-29..

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